Ch. 14 Shock

The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour? 2.7 mL/hr 5.5 mL/hr 8.0 mL/hr 11 mL/hr.

2.7 mL/hr Explanation: The nurse should administer 2.7 mL/hr: 1 mcg/90 kg/60 minutes/2,000 (concentration)

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? Compensatory Progressive Refractory Irreversible

Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? Liver Kidneys Lungs Brain

Brain. Explanation: The body displays a "fight-or-flight" response, with the release of catecholamines. Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. Vomiting Burns Diarrhea Dehydration Trauma

Burns Dehydration Explanation: The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Chart 14-3, p. 308.

A client receives alteplase (t-PA). It is most important for the nurse to intervene when The client's Glasgow Coma Score changes from 15 to 13. A small amount of bleeding occurs at venous puncture sites. The client reports joint pain in the knees and elbows. The client's cardiac rhythm changes to normal sinus with few PVCs.

The client's Glasgow Coma Score changes from 15 to 13. Explanation: Alteplase is a thrombolytic. It is important for the nurse to assess for bleeding. A change in the Glasgow Coma Score may indicate cerebral hemorrhage. Bleeding at venous puncture sites and possibly in the joints is less critical. A normal sinus rhythm with few premature ventricular contractions may be an improvement in the client's cardiac status and indicates lysis of thrombi in the coronary arteries. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 310.

The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation? "Central venous pressure reflects the pressure in the right atrium or venae cavae." "A pulmonary artery pressure provides information about pressure on the left side of the heart." "The trend in central venous pressure is more helpful than isolated readings." "Pulmonary artery pressure and pulmonary capillary pressure is assessed by an inserted catheter.";

"A pulmonary artery pressure provides information about pressure on the left side of the heart." Explanation: The most pertinent information to share with a new nurse is the information that the pulmonary artery pressure provides essential information about the effectiveness of left ventricle. The left ventricle is most pertinent to circulation. The other information is correct but not as pertinent.

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition? 300 mL 400 mL 500 mL 600 mL

300 mL Explanation: An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 316.

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? 40% 50% 60% 70%

70% Explanation: Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 300.

Progressive urinary output characteristics?

<0.5 mL/kg/h p. 299

Compensatory resp characteristics?

>20 breaths/min PaCO: <32 mm Hg Crackles p. 299

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A full liquid diet Isotonic enteral nutrition every 6 hours An infusion of crystalloids at an increased rate of flow A continuous infusion of total parenteral nutrition

A continuous infusion of total parenteral nutrition Explanation: Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation? Select all that apply. Acid-base imbalance Increased capillary permeability and fluid and electrolyte shifts Increased blood urea nitrogen and serum creatinine A mean arterial blood pressure of 70 mm Hg Bradycardia with a heart rate of 60 beats/min

Acid-base imbalance Increased capillary permeability and fluid and electrolyte shifts Increased blood urea nitrogen and serum creatinine Explanation: In decompensation, the MAP would be less than 65 mm Hg, and the heart rate would be tachycardic or erratic with instances of asystole. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? Brachial artery Radial artery Aorta Right ventricular wall

Aorta Explanation: Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 298.

Irreversible cardio characteristics (BP & HR)?

BP: Requires mechanical or pharmacologic support HR: Erratic p. 299

Progressive cardio characteristics (HR & BP)?

BP: Systole <90 mm Hg; MAP <65 mm Hg HR: >150 bpm p. 299

Compensatory cardio characteristics (HR & BP)?

BP: normal HR: >100bpm p. 299

Compensatory mentation characteristics?

Confusion and/or agitation p. 299

Compensatory skin characteristics?

Cold, clammy p. 299

The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by: Cold, clammy skin and tachycardia. A systolic blood pressure of 75 mm Hg. A heart rate of 140. Crackles and shallow breathing.

Cold, clammy skin and tachycardia. Explanation: In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: Constrict blood vessels in the cardiorespiratory system. Decrease heart rate. Relax the bronchioles. Vasodilate the skeletal muscles.

Constrict blood vessels in the cardiorespiratory system. Explanation: Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

Compensatory urinary output characteristics?

Decreased p. 299

Inotropic agents?

Dobutamine (Dobutrex) Dopamine (Inotropin) Epinephrine (Adrenalin) Milrinone (Primacor) p. 307

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? Head injury Myocardial infarction Diabetes Multiple sclerosis

Head injury Explanation: An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 309.

Irreversible skin characteristics?

Jaundice p. 299

Progressive acid-base balance characteristics?

Metabolic acidosis p. 299

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure? Respiratory alkalosis Myocardial depression Rapid, shallow respirations Lethargy and confusion

Myocardial depression Explanation: The body's inability to meet increased oxygen requirements produces ischemia, and biochemical mediators cause myocardial depression. This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 301.

Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respiratiterm-0ons of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? Septic Anaphylactic Neurogenic Cardiogenic

Neurogenic Explanation: The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 318.

Which vasodilator medication is used in the treatment of shock? Dopamine Nitroglycerin Norepinephrine Dobutamine

Nitroglycerin Explanation: Nitroglycerin is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Dopamine and dobutamine are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Norepinephrine is a vasoconstrictor used to increase blood pressure by vasoconstriction. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Table 14-2, p. 311.

Vasodilator agents?

Nitroglycerin (Tridil) Nitroprusside (Nipride) p. 307

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? Nitroprusside Dopamine Epinephrine Methoxamine

Nitroprusside Explanation: A disadvantage of nitroprusside (Nipride) is that it causes hypotension. Dopamine (Intropin) improves contractility, increases stroke volume, and increases cardiac output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

Vasopressor agents?

Norepinephrine (Levophed) Dopamine (Inotropin) Phenylephrine (Neo-Synephrine) Vasopressin (Pitressin) Epinephrine (Adrenaline) p. 307

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Oxygen at 2 L/min by nasal cannula Morphine 2 mg intravenously NS at 60 mL/hr via an intravenous line Dopamine (Intropin) intravenous solution

Oxygen at 2 L/min by nasal cannula Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 311.

Clinical characteristics of neurogenic shock are noted by which type of stimulation? Parasympathetic Sympathetic Endocrine Cerebral

Parasympathetic Explanation: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The client experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 318.

Progressive resp characteristics?

Rapid, shallow respirations, crackles PaO2 <80 mm Hg PaCO2 >45 mm Hg p. 299

What does vasodilators do?

Reduces preload and afterload by reducing O2 demand to the heart Disadvantage is it causes hypotension p. 307

Irreversible resp characteristics?

Requires intubation and mechanical ventilation and oxygenation p. 299

Compensatory acid-base balance characteristics?

Resp alkalosis p. 299

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply. Vital signs Nutrition Skin color Gait Urine output Peripheral pulses

Vital signs Skin color Urine output Peripheral pulses Explanation: Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Clinical Manifestations, p. 301.

11)Which nursing considerations are required when caring for a client being treated for shock who has been administered norepinephrine? Select all that apply.

carefully monitor blood pressure (BP),monitor for photophobia,avoid suddenly discontinuing infusion,monitor for restlessness and palpitations

15)A client who was brought to the ED 3 days ago remains unresponsive in the ICU. Presenting symptoms included elevated temperature and flushed skin; assessment revealed a rapid, bounding pulse. Treatment has been ineffective, and the client's body is no longer compensating for shock symptoms. What are expected changes in this client's condition? Select all that apply.

cellular hypoxiacardiovascular changes

Irreversible urinary output characteristics?

anuric; requires dialysis p. 299

Irreversible mentation characteristics?

unconsciousness p. 299

A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply. heart fails as effective pump blood volume decreases peripheral vascular dilation blunt force trauma nausea

heart fails as effective pump blood volume decreases peripheral vascular dilation Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock develops as a consequence of one of three events: (1) blood volume decreases, (2) the heart fails as an effective pump, or (3) peripheral blood vessels massively dilate (Wedro, 2014). Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 296.

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A full liquid diet Isotonic enteral nutrition every 6 hours An infusion of crystalloids at an increased rate of flow A continuous infusion of total parenteral nutrition

A continuous infusion of total parenteral nutrition Explanation: Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as Cardiogenic Compensatory Progressive Circulatory

Compensatory Explanation: The client's mentation, vital signs, and skin condition are those of a client in the compensatory stage of shock. Data are insufficient to support shock as either cardiogenic or circulatory in origin. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

What does inotropic do?

Improves contractility by increasing stroke volume and increasing cardiac output -Disadvantage is it increases O2 demand to the heart p. 307

Action of vasopressor agents?

Increase BP by vasocontsriction Disadvantage is it increases afterload, increases workload, compromises perfusion to the skin, kidneys, lungs and GI p. 307

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Lung sounds Skin perfusion Bowel sounds Mental status

Lung sounds Explanation: The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 304.

Irreversible acid-base characteristics?

Profound acidosis p. 299

A client with a critical illness has a temperature of 38.5°C (101.3°F). Which parameters will the nurse use to determine if the client is developing sepsis? Select all that apply. Urine output Bilirubin level Platelet count Blood pressure Cardiac rhythm Respiratory rate

Urine output Bilirubin level Platelet count Blood pressure Respiratory rate Explanation: Clients with a critical illness who are demonstrating signs of an infection should be monitored for the developing of sepsis using the Sepsis-Related Organ Failure Assessment Score. The parameters monitored through this score include urine output, bilirubin level, platelet count, blood pressure, and respiratory rate in addition to mean arterial pressure, serum creatinine, and Glasgow Coma Scale score. Cardiac rhythm is not a parameter used to determine the development of sepsis.

A client is unstable and receiving dopamine to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all that apply. Administer through an intact peripheral line. Assess vital signs every hour. Use an intravenous controller or pump. Verify dosage and pump settings with another RN. Measure urine output every hour.

Use an intravenous controller or pump. Verify dosage and pump settings with another RN. Measure urine output every hour. Explanation: It is recommended to administer vasoactive drugs, such as dopamine (Intropin), through a central line. The nurse assesses vital signs every 15 minutes until stable. The nurse uses an intravenous controller or pump to ensure accurate infusion and verifies the dosage and pump settings with another RN. The nurse also measures urine output every hour. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 311.

A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply. antacids H2 blockers proteases proton pump inhibitors promotility agents

antacids H2 blockers proton pump inhibitors Explanation: Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, H2 blockers [e.g., famotidine (Pepcid)], and proton pump inhibitors [e.g., lansoprazole (Prevacid), esomeprazole magnesium (Nexium)] are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Proteases and peptidases split proteins into small peptides and amino acids and help with digestion. A promotility agent such as metoclopramide is used to decrease nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? PaCO2 <32 mm Hg compensatory respiratory alkalosis heart rate >20 bpm metabolic acidosis

compensatory respiratory alkalosis Explanation: In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The Pa CO2 would be increased in compensatory stage of shock. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure? rapid respirations bradycardia low urine output constipation

low urine output Explanation: Tissue perfusion and organ perfusion depend on mean arterial pressure (MAP), or the average pressure at which blood moves through the vasculature. When a MAP falls below 65 mm Hg, a client with progressive shock will have decreased kidney function and low urine output. Clients with low MAP will have tachycardia, slow respirations, and bloody diarrhea. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 301-302.

Progressive mentation characteristics?

Lethergy Loss of consciousness p. 299

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply. The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55-year-old client with spina bifida The client who is scheduled for a repeat CT scan of the abdomen The client with an infection who is prescribed intravenous vancomycin The client who reports an allergy to peanuts that causes throat swelling

The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55-year-old client with spina bifida The client who reports an allergy to peanuts that causes throat swelling Explanation: Risk factors for anaphylactic shock include transfusion reaction, latex allergy, and severe allergy to foods or medications. The client in the first 15 minutes of receiving blood is at risk for an anaphylactic reaction. This is why the nurse should remain in the room for the first 15 minutes of infusion. The client with spina bifida is at risk for a latex allergy, which, in turn, increases the risk for an anaphylactic reaction if latex gloves are used. The client with a peanut allergy is at risk for an anaphylactic reaction if food is prepared or accidentally contaminated with a nut-based oil. The other clients are not at an increased risk for anaphylactic shock. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 314.

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient? The patient has developed a stress ulcer that is bleeding. The patient is having a reaction to the vasoconstricting medications. The patient has a tumor in the esophagus. The patient has bleeding esophageal varices.

The patient has developed a stress ulcer that is bleeding. Explanation: GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 302.

A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing? decompensation stage compensation stage irreversible stage cardiogenic shock

decompensation stage Explanation: Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. This client's symptoms, particularly the dropping BP, indicate the decompensation stage. During the compensation stage of shock, physiologic mechanisms attempt to stabilize the spiraling consequences. During the irreversible stage, the client no longer responds to medical interventions, and multiple systems begin to fail. Cardiogenic shock is a type of shock.

Which of the following is the most common side effect of recombinant human activated protein C (rhAPC)? Bleeding Bone marrow suppression Peripheral edema Muscle cramps

Bleeding Explanation: Bleeding is the most common serious side effect. The nurse monitors closely the response to this treatment, particularly in patients with known bleeding risks, such as chronic liver disease. Bone marrow suppression, peripheral edema, and muscle cramps are not a common side effect of this medication.

A client is scheduled for computed tomography (CT) scanning of the abdomen and reports an allergy to iodine. The best action of the nurse is to Ask the client "How does your allergy manifest itself?" Notify the radiologist of the allergy to iodine. Inform the ordering physician that the CT scan cannot be performed. Send the client for the CT scan, noting the allergy to iodine on the front of the chart.

Ask the client "How does your allergy manifest itself?" Explanation: The nurse must assess the client for reactions to contrast agents. This would include the type of reaction. The nurse then communicates this information to the staff involved in the care of the client. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 319.

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. Assess the client who is at risk for shock. Administer vasoconstrictive medications to clients at risk for shock. Administer prophylactic packed red blood cells to clients at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs.

Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs. Explanation: Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: Blood pressure. Breath sounds. Renal output. Heart rate.

Blood pressure. Explanation: By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 298.

When beta-2 adrenergic receptors are stimulated which of the following occur? Bronchioles relax Vasoconstriction in heart Vasoconstriction in skeletal muscles Bronchioles constrict

Bronchioles relax Explanation: When beta-2 adrenergic receptors are stimulated, vasodilation occurs in the heart and skeletal muscles, and the bronchioles relax, Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? Obstructive Hypovolemic Carcinogenic Distributive

Distributive Explanation: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Distributive Shock, p. 313.

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? Rubbing the hands together with antiseptic solution until dry when exiting the client's room Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration

Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Explanation: The Centers for Disease Control and Prevention do not recommend hanging tape on bedside tables, siderails, linens, or clothing to use for dressings. The other options are activities that are proper infection control practices. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 314.

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply. obtain a urine specimen for culture maintain the IV site inserted on admission institute vital signs every 4 hours administer pantoprazole IV daily monitor urine output every hour

obtain a urine specimen for culture administer pantoprazole IV daily monitor urine output every hour Explanation: The client is exhibiting signs of septic shock. It is important to identify the source of infection, such as obtaining a urine specimen for culture. Medication, such as pantoprazole (Protonix), would be administered to prevent stress ulcers. The nurse would monitor urinary output every hour to evaluate effectiveness of therapy. IV sites would be changed and catheter tips cultured as this could be the source of infection. The client's condition warrants vital signs being assessed more frequently than every 4 hours. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 315.

Progressive skin characteristics?

Mottled, petechiae p. 299

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? "Monitor urine output every hour." "Infuse I.V. fluids at 83 ml/hour." "Administer oxygen by nasal cannula at 3 L/minute." "Draw samples for hemoglobin and hematocrit every 6 hours."

"Infuse I.V. fluids at 83 ml/hour." Explanation: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, pp. 304-305.

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage? Albumin Dextran Lactated Ringer solution Hypertonic saline

Albumin Explanation: Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared with crystalloid solutions. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 305.

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? PaCO2 >45 mm Hg compensatory respiratory alkalosis heart rate <100 bpm metabolic acidosis

compensatory respiratory alkalosis Explanation: In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid. PaCO2 >45 mm Hg, is an expected finding in the progressive state of shock. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. kidney failure disseminated intravascular coagulation acute respiratory distress syndrome hypoglycemia GERD

kidney failure disseminated intravascular coagulation acute respiratory distress syndrome Explanation: When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 298.

Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as sodium nitroprusside. norepinephrine. dopamine. furosemide.

sodium nitroprusside. Explanation: Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Table 14-2, p. 307.

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur? Compensation Irreversible Early Decompensation

Decompensation Explanation: The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis. Therefore, options A, B, and C are incorrect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Respiratory Effects, p. 301.

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered? Levophed Dobutrex Nipride Methotrexate

Levophed Explanation: The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels? distributive cardiogenic hypovolemic organ failure

distributive Explanation: Distributive shock results from displacement of blood volume, creating pooling of blood in the peripheral blood vessels. Cardiogenic shock results from the failure of a heart as a pump. With hypovolemic shock, there is a decrease in the intravascular volume. Organ failure is not a type of shock. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 313.

A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply. nitroglycerin nitroprusside dobutamine dopamine epinephrine

dobutamine dopamine epinephrine Explanation: Dobutamine (Dobutrex), dopamine (Intropin), and epinephrine (Adrenalin) are inotropic agents used to improve client's contractility. Nitroprusside (Nipride) and nitroglycerin (Tridil) are vasodilators used to reduce preload and afterload, reducing oxygen demand in the heart. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

Cardiogenic shock is most commonly seen in which patient population? Myocardial infarction Spinal cord injury Head injury Stroke

Myocardial infarction Explanation: Cardiogenic shock is seen most often in patient with myocardial infarction. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 310.

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? 0.9% sodium chloride Lactated Ringer's Albumin Dextran

Lactated Ringer's Explanation: Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 304.

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next? ondansetron meperidine magnesium hydroxide loperamide

ondansetron Explanation: An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 309.

En route to the emergency room, a client's systolic blood pressure (BP) was 96 mm Hg and falling. Which systolic BP supports the diagnosis of septic shock? Select all that apply. 72 mm Hg 80 mm Hg 98 mm Hg 102 mm Hg 108 mm Hg

72 mm Hg 80 mm Hg 98 mm Hg Explanation: For a normotensive adult, average systolic BP is 120 mm Hg. Therefore, a systolic BP of 90 to 100 mm Hg indicates impending shock, whereas 100 mm Hg or below indicates septic shock. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces. Generally caused by decreased blood volume. Due to severe hypersensitivity reaction resulting in massive systemic vasodilation.

A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Explanation: Shock may have different causes (e.g., hypovolemic, cardiogenic, septic) but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Option B could reflect dependent edema and sepsis. Option C reflects hypovolemia. Option D is reflective of anaphylactic or distributive shock. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 310.

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.) A heart rate >100 bpm Crackles Lethargy and mental confusion Respirations <15 breaths/min Compensatory respiratory acidosis

A heart rate >100 bpm Crackles Lethargy and mental confusion Explanation: In compensatory shock, the heart rate is >100 bpm, the patient experiences lethargy and mental confusion, respirations are >20 breaths/min (not <15), and respiratory alkalosis is present (not respiratory acidosis). Subsequent decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Respirations are rapid and shallow. Crackles are heard over the lung fields. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

Which colloid is expensive but rapidly expands plasma volume? Albumin Dextran Lactated Ringer solution Hypertonic saline

Albumin Explanation: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 305.

What is the consequence of the release of catecholamines in the skeletal muscles during the compensation stage of shock? Blood supply to the skeletal muscles increases. Blood supply to the body decreases. The amount of air that enters the lungs decreases. The liver releases glycogen to provide energy.

Blood supply to the skeletal muscles increases. Explanation: Catecholamines cause the dilatation of arterioles in the skeletal muscles that increases their blood supply. The release of catecholamines increases the heart rate and the blood supply to the body. The release of catecholamines causes bronchial dilatation to increase the amount of air that enters the lungs. Glycogen release is a consequence of the release of catecholamines in the liver, not the skeletal muscles.

The nurse is caring for a 78-year-old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop? Cardiogenic shock Neurogenic shock Septic shock Anaphylactic shock

Cardiogenic shock Explanation: Cardiogenic shock occurs when the heart's ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and the tissues. Older adults, particularly those with cardiac disease, are susceptible to cardiogenic shock. Older adults are not susceptible to developing neurogenic, septic, or anaphylactic shock. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 310.

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock? Circulatory (distributive) Cardiogenic Hypovolemic Obstructive

Circulatory (distributive) Explanation: Vasodilatation, a prominent characteristic of circulatory/distributive shock, increases the space in the vascular bed. Central blood flow is reduced because peripheral vascular or interstitial areas exceed their usual capacity. Vasodilation is not a major component of cardiogenic, hypovolemic, or obstructive shock. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 313.

What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? Reduced preload. Reduced afterload. Increased cardiac output. Decreased blood pressure.

Decreased blood pressure. Explanation: A potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently according to the manufacturer's recommendation and institutional policy. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? The client with pneumonia in the left lower lobe of the lung The client with a BMI of 25 who has lost 3 pounds as the result of vomiting The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs) The client with testicular cancer who is receiving intravenous chemotherapy

The client with testicular cancer who is receiving intravenous chemotherapy Explanation: Risk factors for septic shock include immunosuppression, such as with the client who has testicular cancer and is receiving chemotherapy. Other risk factors include age younger than 1 year or greater than 65 years, malnourishment, chronic illness, and invasive procedures. None of the other clients meets these risk factors or has a greater risk for invasive procedures than the client with testicular cancer. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 314.

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: The balloon deflates prior to systole. The right foot is cooler than the left foot. Vesicular breath sounds are audible in the lung periphery. Bilateral pedal pulses are 1+.

The right foot is cooler than the left foot. Explanation: When a client has an intra-aortic balloon counterpulsation, he or she is at risk for circulatory problems in the leg in which the catheter has been inserted. In this case, it is the right leg. A complication would be a right foot that is cooler than the left foot. Pedal pulses of 1+ bilaterally would not be a complication of this therapy but of other problems. The balloon is supposed to deflate prior to systole. It is normal for vesicular breath sounds to be audible in the lung periphery. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 312.

How should vasoactive medications be administered? Using a central venous line Through a peripheral IV line Intramuscularly (IM) By rapid intravenous (IV) push

Using a central venous line Explanation: Vasoactive medications should be administered through a central venous line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV push. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 317.

A nurse is assessing a client who is experiencing significant stress due to septicemia. Drag words from the choices below to fill in each blank in the following sentence. maintain prone position obtain the lactate level maintain prone position obtain the lactate level maintain prone position obtain the lactate level

administer oxygen therapy, obtain the lactate level, and monitor temperature. Explanation: The nurse should expect to administer oxygen therapy to support perfusion, monitor temperature to assess metabolic response, and obtain lactate levels, which serve as a critical predictor of the client's metabolic stress response. The nurse should not place a client with septicemia in a prone position because this would lead to further respiratory compromise. The nurse should not increase PO fluid intake because this would also lead to respiratory compromise and fluid volume overload.

The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.) Increased intravascular volume Activation of the inflammatory response Hypoperfusion of tissues Must produce energy through anaerobic metabolism Increase in cellular Activity

Activation of the inflammatory response Hypoperfusion of tissues Must produce energy through anaerobic metabolism Explanation: Regardless of the initial cause of shock, certain physiologic responses are common to all types of shock. These physiologic responses include hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response. The body responds to shock states by activating the sympathetic nervous system and mounting a hypermetabolic and inflammatory response. Failure of compensatory mechanisms to effectively restore physiologic balance is the final pathway of all shock states and results in end-organ dysfunction and death. In shock, the cells lack an adequate blood supply and are deprived of oxygen and nutrients; therefore, they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients and an acidotic intracellular environment. Because of these changes, normal cell function ceases (Fig. 14-1). The cell swells and the cell membrane becomes more permeable, allowing electrolytes and fluids to seep out of and into the cell. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 297.

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? Administer recombinant human activated protein C (rhAPC) as prescribed. Begin a continuous IV infusion of insulin per protocol. Initiate enteral feedings as prescribed. Administer norepinephrine as prescribed.

Administer norepinephrine as prescribed. Explanation: Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Table 14-2, p. 316.

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits A change in apical pulse rate from 102 to 88 beats/min Adventitious breath sounds Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute Troponin levels less than 0.35 ng/mL

Adventitious breath sounds Explanation: The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 305.

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? Unstable angina pectoris Aortic insufficiency Hypertension Diabetes mellitus

Aortic insufficiency Explanation: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 312.

A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse Begins the enteral nutritional supplement at 100 mL/hr to ensure adequate calories Measures the nasogastric tube from earlobe to xiphoid process and marks the tube with tape at this level Consults with the physician about substituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) Obtains consent by a family member for placement of a percutaneous endoscopic gastrostomy (PEG) tube

Consults with the physician about substituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) Explanation: Pantoprazole tablets are not to be broken, crushed, or chewed. Lansoprazole is substituted for this medication. The nurse consults with the physician about substituting another proton pump inhibitor for pantoprazole. Enteral feedings are initiated at a slow rate to ensure adequate digestion. The nasogastric tube is measured from earlobe to xiphoid process and 6 inches are added to the length of the tube to be inserted. Placement of a PEG tube is not necessary at this time. The client is unstable. The tube is meant for long-term, not short-term, placement. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client? Control the shivering. Place the client on a warming blanket. Keep the client dry and covered. Maintain the client in a supine position with legs elevated 12 inches.

Control the shivering. Explanation: Hyperthermia may develop related to altered temperature regulation secondary to sepsis. Because the act of shivering increases body heat through the contraction of skeletal and pilomotor muscles in the skin, it is important to get the shivering under control. Use of a warming blanket would not be an appropriate intervention because this client is septic and hyperthermic. Conduction and radiation transfer heat, which would increase the client's body temperature. Keeping the client dry and covered would not help this situation because measures that prevent evaporation and heat loss from radiation interfere with the loss of body heat. Supine positioning with elevated legs is appropriate for clients with ineffective peripheral tissue perfusion. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 317.

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is Packed red blood cells Salt-poor albumin Plasma Dextran

Dextran Explanation: Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 308.

The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock? Hypervolemic Distributive Restrictive Cardiotonic

Distributive Explanation: The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. This makes options A, C, and D incorrect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Distributive Shock, p. 313.

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply. Hypovolemic shock; blood loss Obstructive shock; kidney stone Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Septic shock; infection Neurogenic shock; diabetes

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Septic shock; infection Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interfere in blood flow through the heart . Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Overview of Shock, p. 296.

You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client? Increases myocardial contractility Decreases blood return to the heart Decreases carbon dioxide exchange Contracts bronchioles

Increases myocardial contractility Explanation: To compensate in shock, the sympathetic nervous system releases endogenous catecholamines, adrenaline and noradrenaline, into the circulation. Adrenaline and noradrenaline increase heart rate and myocardial contractility, which may be counterproductive in cardiogenic shock because it increases a demand for oxygen by an already compromised heart. Venous return to the right atrium subsequently increases, as does blood sent to the lungs. Bronchial dilatation increases the amount of oxygenated air entering the lungs, followed by a more efficient exchange of oxygen and carbon dioxide (CO2). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? Precompensatory Compensatory Progressive Irreversible

Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

The nurse is caring for a client with a central venous line in place for the treatment of shock. Which nursing interventions are essential for the nurse to complete in order to reduce the risk of infection? Select all that apply. Maintain sterile technique when changing the central venous line dressing. Always perform hand hygiene before manipulating or accessing the line ports. Apply clean gloves before accessing the line port. Perform a 10-second "hub scrub" using chlorhexidine and friction in a twisting motion on the access hub. Instruct the client to wear a face mask and gloves while the central venous line is in place.

Maintain sterile technique when changing the central venous line dressing. Always perform hand hygiene before manipulating or accessing the line ports. Apply clean gloves before accessing the line port. Explanation: The following nursing interventions are essential to reduce the risk of infection: maintain sterile technique when changing the central venous line dressing; always perform hand hygiene before manipulating or accessing the line ports; apply clean gloves before accessing the line port; and perform a 15- to 30-second "hub scrub" using chlorhexidine or alcohol and friction in a twisting motion on the access hub. The latter reduces biofilm on the hub that may contain pathogens. Chart 14-2

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? Increase in diastolic pressure Decrease in respiratory rate Increase in systolic blood pressure Narrowed pulse pressure

Narrowed pulse pressure Explanation: Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 300.

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? Refractory Compensatory Irreversible Progressive

Progressive Explanation: In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Table 14-1, p. 301.

The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines? T3 and T4 Myoglobin and CK-MB BUN and creatinine Sodium and glucose levels

Sodium and glucose levels Explanation: In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family? The client has lost too much blood. The client is brain dead. The client is not responding to medical interventions. The client has given up.

The client is not responding to medical interventions. Explanation: The irreversible stage occurs when significant cells and organs become damaged. The client's condition reaches a "point of no return" despite treatment efforts. The client no longer responds to medical interventions. Multiple systems begin to fail. When the kidneys, heart, lungs, liver, and brain cease to function, death is imminent. Options A, B. and D are not indicated in the scenario, and therefore, are incorrect. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 303.

When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal? Improve the heart's pumping mechanism Limit further myocardial damage Preserve the healthy myocardium Treat the oxygenation needs of the heart muscle

Treat the oxygenation needs of the heart muscle Explanation: As with all forms of shock, the underlying cause of cardiogenic shock must be corrected. It is necessary first to treat the oxygenation needs of the heart muscle to ensure its continued ability to pump blood to other organs. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, pp. 310-311.

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) Urinary output Mental status Vital signs Ability to perform range of motion exercises Visual acuity

Urinary output Mental status Vital signs Explanation: Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. The patient receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 305.

A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply. norepinephrine milrinone epinephrine vasopressin phenylephrine

norepinephrine vasopressin phenylephrine Explanation: The vasopressive agents that may be used in managing a client with cardiogenic shock include norepinephrine (Levophed), vasopressin (Pitressin), and phenylephrine (Neo-Synephrine). The vasopressive agents increase blood pressure by constriction. Milrinone (Primacor) is an inotropic agent that improves contractility. Epinephrine is both a vasopressor and an inotropic agent. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 307.

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply. obtain a urine specimen for culture maintain the IV site inserted on admission institute vital signs every 4 hours administer pantoprazole IV daily monitor urine output every hour

obtain a urine specimen for culture administer pantoprazole IV daily monitor urine output every hour Explanation: The client is exhibiting signs of septic shock. It is important to identify the source of infection, such as obtaining a urine specimen for culture. Medication, such as pantoprazole (Protonix), would be administered to prevent stress ulcers. The nurse would monitor urinary output every hour to evaluate effectiveness of therapy. IV sites would be changed and catheter tips cultured as this could be the source of infection. The client's condition warrants vital signs being assessed more frequently than every 4 hours. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 315.

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? Two large-bore IVs and begin crystalloid fluids 100% oxygen via a nonrebreather mask C-spine x-rays Type and cross match

100% oxygen via a nonrebreather mask Explanation: The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied via a nonrebreather mask. The other orders should be completed after the client's airway is secure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? Within normal limits Thready 24 Palpable

24 Explanation: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Monitoring Tissue Perfusion, p. 300.

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.) A heart rate >100 bpm Crackles Lethargy and mental confusion Respirations <15 breaths/min Compensatory respiratory acidosis

A heart rate >100 bpm Crackles Lethargy and mental confusion Explanation: In compensatory shock, the heart rate is >100 bpm, the patient experiences lethargy and mental confusion, respirations are >20 breaths/min (not <15), and respiratory alkalosis is present (not respiratory acidosis). Subsequent decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Respirations are rapid and shallow. Crackles are heard over the lung fields. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? A rapid, bounding pulse A slow but steady pulse A weak and thready pulse A slow and imperceptible pulse

A rapid, bounding pulse Explanation: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Sepsis and Septic Shock, p. 313.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next Administers oxygen by nasal cannula at 2 liters per minute Re-assesses the vital signs Contacts the admitting physician Calls the Rapid Response Team

Administers oxygen by nasal cannula at 2 liters per minute Explanation: The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? Serum thyroid level findings Arterial blood gas (ABG) findings Red blood cells (RBCs) and hemoglobin count findings White blood cell count findings

Arterial blood gas (ABG) findings Explanation: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid level findings do not help determine the presence of hypoxemia or metabolic acidosis.

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? Initial stage Compensatory stage Progressive stage Irreversible stage

Compensatory stage Explanation: In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

The nurse is caring for a client in the compensation stage of shock. The nurse knows that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do? Decreases peripheral blood flow Increases catecholamine secretion Increases the production of antidiuretic hormone Restores blood pressure

Restores blood pressure Explanation: The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Compensatory Stage, p. 299.

A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply. Dopamine Dobutamine Nitroglycerin Diphenhydramine Vasopressin

Dopamine Dobutamine Nitroglycerin Vasopressin Explanation: Dopamine is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. It may be used with dobutamine and nitroglycerin to improve tissue perfusion. Dobutamine produces inotropic effects by stimulating myocardial beta-receptors, increasing the strength of myocardial activity and improving cardiac output. Myocardial alpha-adrenergic receptors are also stimulated, resulting in decreased pulmonary and systemic vascular resistance. Intravenous nitroglycerin in low doses acts as a venous vasodilator and reduces preload. At higher doses, nitroglycerin causes arterial vasodilation and reduces afterload as well. These actions, in combination with dobutamine, increase cardiac output while minimizing cardiac workload. In addition, vasodilation enhances blood flow to the myocardium, improving oxygen delivery to the weakened heart muscle. In addition, vasopressin is another agent used to manage cardiogenic shock. Diphenhydramine is indicated in anaphylactic shock rather than cardiogenic shock, and can be given intravenously to reverse the effects of histamine.

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? Shock begins in the decompensation stage. In the compensation stage, catecholamines are released. Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage. The renin-angiotensin-aldosterone system fails in the compensation stage.

In the compensation stage, catecholamines are released. Explanation: Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, pp. 298-299.

The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? Decreased white blood cell count Increase in arterial oxygenation Decreased depressive symptoms Regulation of sodium and potassium

Increase in arterial oxygenation Explanation: Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Compensatory Stage, p. 299.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae Decreases in liver enzymes

Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae Explanation: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activities of the liver are impaired, and liver enzymes will increase. Table 14-1 p. 299

The nurse is caring for a client who develops hypotension, declining mental status, and severely decreased urinary output. Which intravenous fluid will the nurse expect to be prescribed for this client? Lactated Ringer's solution 0.9% normal saline 3% sodium chloride Dextrose 5% and 0.9% normal saline

Lactated Ringer's solution Explanation: This client is demonstrating symptoms of the progressive stage of shock, and fluid replacement is indicated. Intravenous crystalloids commonly used for resuscitation in hypovolemic shock include lactated Ringer's solution. This is an electrolyte solution that contains lactate ions which are converted to bicarbonate which helps buffer the acidosis that occurs in shock. Lactated Ringer's also most closely resembles plasma and is considered a more appropriate first choice solution over 0.9% normal saline. Even though 0.9% normal saline is an isotonic solution, large infusions may cause hypernatremia, hypokalemia, and hyperchloremic metabolic acidosis. Hypertonic crystalloid solutions such as 3% sodium chloride do not improve client outcomes and may cause unintended complications. Because of this, 3% sodium chloride is not recommended for fluid resuscitation. Dextrose 5% and 0.9% normal saline is not appropriate for fluid resuscitation.

A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first Maintains the head of the bed at 30 degrees Lays the client flat with the feet elevated Administers a bolus of intravenous (IV) fluids Assesses the client's blood glucose level

Lays the client flat with the feet elevated Explanation: The client may have fainted, which is a sign of transient neurogenic shock. To minimize pooling of blood in the legs and to restore blood flow to the brain, the nurse lays the client flat and elevates his or her feet. Another cause may be hypoglycemia. If the above action does not resolve the client's problem, the nurse should assess the client's blood glucose level. Raising the head of the bed would be done if the client had received spinal or epidural anesthesia. A bolus of IV fluids would be given if the client were dehydrated. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 309.

The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body? Activation of renin-angiotensin-aldosterone system Secretion of epinephrine and norepinephrine Production of antidiuretic hormone and corticosteroid hormones Release of catecholamines

Production of antidiuretic hormone and corticosteroid hormones Explanation: Thus, antidiuretic hormone (ADH) and corticosteroid hormones play an active role in controlling sodium and water balance. Both ADH and corticosteroid hormones, then, promote fluid re absorption and retention. The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. The release of catecholamines stimulates secretion of epinephrine and norepinephrine. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, Compensatory Stage, p. 299.

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as Hypovolemic Progressive Neurogenic Compensatory

Progressive Explanation: The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 299.

A client experienced hemorrhage following a gunshot to the chest and received massive amounts of fluids. The client is now stable. The nurse assesses abdominal pressure as 12 mm Hg. The most immediate nursing intervention is to Raise the head of the client's bed. Turn the client every 2 hours. Insert a rectal tube for decompression. Begin measurements of abdominal girth.

Raise the head of the client's bed. Explanation: Normal abdominal pressures are 0 to 5 mm Hg. The client may be experiencing abdominal compartment syndrome, an increase in the pressure of the abdominal cavity. This is from fluid leaking into the intra-abdominal cavity and results in elevating the client's diaphragm. Raising the head of the bed will promote easier breathing. The other options may be done by the nurse, but ensuring adequate oxygenation is the priority. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 303.

A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse Elevates the head of the client's bed Raises the foot of the client's bed Turns the client to a side-lying position Places the client in a Trendelenburg position

Raises the foot of the client's bed Explanation: The description of the client is that of a person experiencing shock. In addition to administering fluids to a client in shock, the nurse positions the client with the legs elevated, which promotes venous blood return. Elevating the head of the bed will cause the client's blood pressure to drop even more. The Trendelenburg position will make breathing difficult and does not increase blood pressure or cardiac output. Placing the client in a side-lying position does not increase venous blood return. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 309.

The nurse provides care for a client who is diagnosed with shock and who is at risk for multiple organ dysfunction syndrome (MODS). Complete the following sentence by choosing from the lists of options. Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of Dropdown Item 1 as evidenced by Dropdown Item 2. acute lung injury (ALI) shortness of breath hypermetabolic state a drop in blood pressure hepatic dysfunction an increase in heart rate renal dysfunction left-sided weakness

acute lung injury (ALI) as evidenced by shortness of breath . In multiple organ dysfunction syndrome (MODS), the sequence of organ dysfunction varies depending on the client's primary illness and comorbidities before experiencing shock; however, the lungs are often the first organ to show dysfunction. The client who is at risk for MODS should be assessed for the first symptom that often accompanies this diagnosis, which is acute lung injury (ALI). Symptoms associated with ALI include shortness of breath (i.e., dyspnea) and respiratory failure. Although the first presentation of MODS is often ALI, the client is also at risk for developing a hypermetabolic state, hepatic dysfunction, and renal dysfunction. Although the client may experience a drop in blood pressure and an increased heart rate with MODS, the heart and circulatory system are not affected first by this diagnosis. Left-sided weakness is associated with a right-sided stroke and not MODS.

The nurse is concerned that a client is developing multiple organ dysfunction syndrome (MODS). Place the signs/symptoms in the classic sequence in which this syndrome develops. 1 lung dysfunction 2 fluid balance 3 hypermetabolism 4 liver dysfunction 5 kidney dysfunction 6 bleeding disorder 7 cardiovascular instability 8 neurologic deterioration

lung dysfunction fluid balance hypermetabolism liver dysfunction kidney dysfunction bleeding disorder cardiovascular instability neurologic deterioration The classic pattern for the development of MODS begins with the lungs as the client experiences progressive dyspnea and respiratory failure. Increasing amounts of IV fluids and vasoactive agents are then needed to support blood pressure and cardiac output. Signs of a hypermetabolic state occur next, which is characterized by hyperglycemia, hyperlactic acidemia, and an increased blood urea nitrogen level. After 7 to 10 days, signs of liver dysfunction (elevated bilirubin and liver function tests) and kidney dysfunction (elevated creatinine and anuria) develop. As the lack of tissue perfusion continues, the hematologic system becomes dysfunctional, which increases the risk of bleeding. The cardiovascular system becomes unstable and unresponsive to vasoactive medications, and the neurologic system deteriorates to a state of unresponsiveness or coma.